Form Gimc - Georgia Intrastate Motor Carrier Registration (Gimc) Application

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Form GIMC (Rev. 4/2013)
State of Georgia Department of Revenue
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Georgia Intrastate Motor Carrier Registration (GIMC) Application
SECTION 1: GENERAL INFORMATION
Please indicate Registration Year 20______
US DOT Number
MC Number
MCA Number
Email Address
State Tax ID Number
FEIN
SSN
Telephone Number
Fax Number
Legal Name
Doing Business Under the Following Name (DBA)
Principal Place of Business (Street Address)
City
State
ZIP Code
Mailing Address
City
State
ZIP Code
OFFICERS
For Corporations, Limited Liability, and where applicable please list
1. Name:
Address
City
State
ZIP
2. Name:
Address
City
State
ZIP
Note:
Please list additional Officers including Address and Contact information on the back of this form and return
with application.
SECTION 2: CLASSIFICATION- Please Check All That Apply
Motor Carrier
Private Motor Carrier
Motor Carrier transporting Hazardous Material
SECTION 3: NUMBER OF VEHICLES AND FEES
Please include all motor vehicles that travel EXCLUSIVELY in Intrastate Commerce
Total # of Motor Vehicles
multiply (x) per vehicle
Total Fees Due
x $5.00 before January 1st or if a New Applicant
= $
x $25.00 after January 1st
SECTION 4: CERTIFICATION
The above described applicant hereby applies for the registration of intrastate UCR of the vehicle or vehicles which it operates within or
through the borders of Georgia during the period for which such registration is effective. The operation of such vehicle or vehicles shall be
in accordance with O.C.G.A. § 40-2-140.
I, the undersigned, under penalty for false statement, certify that the above information is true and correct and that I am authorized to
execute and file this document on behalf of the applicant.
(Print) Name of Owner or Authorized Representative
Date
Signature
Title
Mailing Address: Georgia Department of Revenue, Motor Vehicle Division, PO Box 740382, Atlanta, Georgia 30374-0382
E-mail:
commercial.vehicles@dor.ga.gov
Telephone: 1-855-406-5221

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